Ugandahttp://www.rcpsych.ac.uk//discoverpsychiatry/overseasblogs/uganda.aspxUganda Blog: Dr Peter Hughes is a UK psychiatrist based at Springfield University Hospital, London. He has an interest in international psychiatry and has been travelling to Africa over the last five years doing short-term assignments in mental health. http://www.rcpsych.ac.uk/Images/rss_feed1.jpgUgandahttp://www.rcpsych.ac.uk//14456Alterian CMCSun, 18 Feb 2018 06:46:18 GMTen-usRefugee mental health needs in UgandaResponding effectively to mental health needs amongst
refugees is now a major healthcare challenge in Uganda

Lord Nigel Crisp’s report: “Global
health partnerships: the UK contribution to health in developing
countries,” has led to several steps being taken by the
Health Education England in support of healthcare professionals
from the National Health Service (NHS) wishing to volunteer in
developing countries. A successful global health partnership
essentially works on the principle of co-development, that is
having a positive and sustainable impact for all partner countries.
Ensuring co-development through volunteerism is even more
challenging.

The Uganda UK Health Alliance (UUKHA) was established to assist
with this co-development concept (http://www.uukha.org/). The
alliance helps to bring together all UK health initiatives
operating in Uganda, with the objective of ensuring alignment of
these initiatives with Uganda’s own strategic health priorities.
Through UUKHA, several member organisations have identified that
refugee health care is a key national strategic priority in
Uganda.

In September 2017, we were involved in a scoping visit to
Northern Uganda which sought a better understanding of the current
Uganda government policy on refugee health care. A consortium
including the Uganda Red Cross Society, Everton Football club
(Everton in the Community) and Health Education England (through
its Global Health Exchange), aimed to explore advocacy for mental
health care and psychosocial support through sport for refugees in
Uganda.

Uganda is currently facing an influx of refugees and migrants on
an unprecedented scale (Currently>1.3 million people). Entire
families have fled their homes; escaping war, political
persecution, human rights violations from South Sudan and other
neighbouring countries. Upon reaching, Uganda, new refugees receive
health care from refugee support centres set up by both government
and non-governmental organisations such as the Uganda Red
Cross.

As we travelled through northern Uganda on our way to the Imvepi
and later to the Bidi Bidi refugee settlement (a huge refugee camp
spanning 75km and takes 2 hours to drive from one end to another),
we observed that the landscape gradually changed from proper
housing structures to small tents made from white plastic and
emblazoned with the letters UNHCR.

During our time in the refugee settlement camps, we heard
many stories that were disturbing from a human rights
perspective;detainees having faced unlawful killing of their
relatives, torture, heavy and indiscriminate shelling of civilian
areas, enforced disappearances, the systematic denial, in some
areas, of food and water, destruction and looting of property. We
observed a concerted effort by the Ugandan government and
humanitarian organizations, such as Red Cross to alleviate the
physical suffering of the amassed refugees. This is of great
importance and very challenging as services are required to
meet the basic needs of both the local and refugee populations
with limited resources.

Whilst we observed efforts aimed at disease
prevention through improved nutrition and sanitation programmes
such as WASH, there was often little treatment or support provided
for the less visible, mental scars from the refugees’ war journeys.
With the sheer number of refugees and migrants arriving in Uganda
each week, it is worrying that mental health care and psychosocial
support are frequently overlooked.

What is clear from our visit to refugee settlements in Northern
Uganda, is that the level of mental healthcare provided by the
host country is woefully short of the demand from the burgeoning
refugee population. However, it is very important to
acknowledge that these refugees are coming to a country where there
are very few mental health services and limited expenditure on
mental health support for the local population (Kigozi, Ssebunnya,
et al, 2010). Whilst access to mental health support may be
limited due to overstretched resources in Uganda, providing this
support for refugee population is a basic need that has to be
catered to.

We found that Red Cross volunteers are embedded within both the
local and refugee communities and are able to not only understand
the of taboos and cultural specificities within refugees
communities, but also skills in building trust to ensure that a
dialogue can be built with the local community so that the mental
health issues can be addressed effectively. Many of the
services made available by both government and non-governmental
organisations encounter barriers to engagement, and there are
significant challenges for health advocates trying to bridge the
gap between service provider and refugee community. We therefore
recommend that there is a collective humanitarian effort to provide
training for the health sector workers and volunteers to improve
their understanding of the health needs of refugees.

Moses is a Health Research Postgraduate from Centre of Evidence
Based Medicine, Oxford University

Moses currently works as the UK Coordinator of Uganda UK
Health Alliance.

Claire Cheminade is a UKPHR Registered Public Health
Practitioner (PR0044) and Senior Project Manager for the
Population Health and Prevention Team at Health Education England
(HEE)

Dr John Paul Bagala is a Medical Doctor who does part-time
practice with Uganda's Mulago National Referral Hospital,
Department of Nephrology and the current Country Director for the
Uganda UK Health Alliance in Uganda.

Day fourteen - Stick
out like sore thumbs

We hang around doing paperwork and emails
although Uganda has terrible internet access, or at least for me.
We go to a restaurant near the airport and spend a few hours
working. Erin and I go to a beach club. We are the only
non-Ugandans there so stick out like sore thumbs. But that's not
a problem as people in Uganda are laid back.

Days fifteen to seventeen
- Frantic days

These are the last frantic days of the
workshop. We are trying to desperately catch up on any
lost time.

As expected, the first few days in the
previous week took a while to warm up. Now there is pressure to
finish the design document in time...or at least the main body and
budget. It's frantic during the day and frantic at night as we
get all design products trimmed and ready.

At the last day of workshop we have actually
got something that looks good and we can be proud of. It is a
Ugandan document. As outsiders we have been able to advise and
honour the donor requirements but not take over. There is a
photo opportunity and final prayers. Then my colleagues fly off
while I have another day to go before I catch my
flight

Days eighteen - Chimpanzee
sanctuary

I spent the morning watching chimpanzees. There was one chimp
looking a bit isolated and miserable. It looked at the leaflet
and saw that there was indeed a chimp who suffered from depression.
This day was taking me to a whole new world of mental health –chimp
mental health.

I write this on my last day in Uganda at
Entebee airport. I can’t say I have endured any hardships here even
if power and internet is unreliably. Uganda is a beautiful country
and is secure. The people have been kind and gracious hosts.
They are committed to improving mental health. Nodding disease is
becoming a real concern and time will tell what happens with this
bizarre disease and its increasing cases in the North district.

This morning I walked down to the lapping
shores of Lake Victoria. This is an idyllic place. The weather is
warm and really perfect.

As I walk down the corridor in the hotel,
in front of me is a typical view. There are
about five small groups working mostly in French on domestic
violence, agriculture, Malawians with fisheries, Bangladeshi
soldiers. We have had a weekend of pentacostalists at the Hotel.
Its NGO land in this hotel...and Russia.

So this blog is not about “exciting” clinical
work or training but about being stuck in a classroom
effectively talking through paperwork and money. It doesn’t sound
exciting. However I think that because we have participated in
such a tight design document the project has a great chance
of success and will really make a difference to Uganda. The
idea of the user groups being such a core part of the project was a
real surprise to me and seemed really interesting and
translatable.

The other thing I learned about was
interpersonal therapy which I had never really understood before.
It has significant evidence base. A practitioner explained it to me
and all those I spoke to who use it in Uganda seem to love it.
Patients love it. It is used for depression primarily. In Uganda
mainly it is used as group work. It was a big take home message for
me in CBT UK.

It was a pleasure being part of this process
and I thank the Ugandan Ministry of Health, World Vision Australia,
WHO and all my professional colleagues for this experience - I
learnt a lot from them. Take home messages I got were the value of
careful planning of projects, user groups, interpersonal therapy
and the value of a strong mental health advocate in the
Government.

I'm both fascinated and confident
that this project will be a success.

Day five - Desk
review

Desk review - this was something new! It's
similar to preparing a review paper. You assemble information
related to health in Uganda at all levels
and then prepare a report based on this.

This was beyond tedious! I wondered whether
this would be helpful or not.

From discussions, I do now realise that this
is an important part of the process which fleshes out the
background for the task ahead and feeds into a formal report. It
helped me understand Uganda's health needs. It also helped me
participate in a workshop.

This is hard, dry work but useful.

Days six and
seven - Entebbe

Desk review continues each day as it is an
ever expanding task. I'm sent papers from all sides to incorporate
into the desk review. At the end I feel like I have something
that is reflective of the information I have...although some of the
data seemed out of date in 2012.

Wondering around Kampala: Mark from WHO Geneva
is a welcome addition to our group. Over the last few
years, I have been in contact with Mark about mhGAP and
different projects. It was nice to spend time with him in
person rather than email. I learned a lot from Mark about
international work and WHO. He's a master of technical knowledge as
well as very nice company.

On Sunday we travel to Entebbe. Entebbe is
either a very tiny place or I missed most of it. There are a few
roads and little traffic. Bizarrely the hotel seemed populated
by lots of Russians as well as the expected NGOs.

I expected mosquitoes and got none
- instead I had lake flies.On arrival at the hotel
I had so many lake flies in my hotel room -1000s if not millions
that I slept in the bathroom. It was literally a carpet of insects
by the morning. I have never seen anything like it.

We had a buffet at the hotel - this was a
place we began to hate!

Days eight to twelve -
Workshop

This was the meat of the trip and a new type
of process for me. Designing the mhGAP project in Uganda may
have been long and sometimes exquisitely tedious, but by
the end I realised how this would ensure that the project would
work.

This is a Ugandan project that World
Vision sponsors - WHO provides technical advice and the owners
are the Ugandan health services and ministry. So there was a
variety of stakeholders at the meeting including psychiatrists,
psychologists, ministry people, NGOs representing epilepsy and
psychosocial work. My role was a bit less clear in my mind. I was
there to share my modest experiences of mental health in
international primary care work.

There were new terms for me to learn and
understand: log frame, detailed implementation plan, monitoring and
evaluation as well as budgeting. The workshop day begins with
prayers and end with prayers.

Ugandans like to talk and there's lots of
participation. Chairing was a challenge and I did my share. There
was lots of enthusiasm and ideas. Log frame means the logical
framework. This was the core of the workshop which is
about the skeleton of the design. It consists of a table
featuring goal, outcome, output, indicators, and assumptions. This
took the bulk of the whole workshop and is the base for the
implementation. We ended up with a goal and several outcomes. The
workshop fleshed these out with input from all stakeholders.

Detailed implementation plan is a plan to role
out the outputs and outcomes with a time line. The budgeting
discussions were predictably difficult. As normally happens
the initial budget goes well over budget and then needs to be
painfully trimmed down.The end result was a design which was scaled
down, realistic, achievable but still valuable for patients with
mental, neurological and substance use problems in Uganda.

What was very interesting was the input on
user groups. This became an important part of the
discussions and became a structural part of the design. User
groups would be able to combat stigma, publicise and market
clinics. They would drive the momentum for the service to
continue. My own feeling was that epilepsy would be a key condition
that could generate its own market. The community will see the
benefit of treatment and insist on treatment continuing long into
the future. Something I had seen previously in Chad.

By day five I was so shattered that I
realised that doing direct clinical work or training –the
“exciting” stuff - is actually less exhausting.

Day thirteen - Day off

This was a great day. Dr. Mugaga was our
wonderful host who took us sightseeing. We saw waterfalls
and were taken to schools with unbelievably well-behaved school
children. We also went to the source of the Nile in Jinga
District and had a boat trip. Dinner was with Word Vision in
Kampala then back to Entebbe.

Day one - London

I leave London Heathrow in Emirates new Airbus
A380. Those who know me will know exactly how delighted I was be to
go on this for the first day. And it didn’t disappoint. This is the
only way to fly – even down the back.

Day two - Kampala

Arrive in Entebbe airport and I'm carted off
to Kampala which is about an hour’s journey. The hotel is huge and
incredibly dark.

Kampala seems like a nice town to me. Warm
weather. Gentle hills. I just can’t see many people around. Unlike
other places I go to it is amazing to be able to go outside without
security briefing and a security guard. It is a really safe place
apart from petty crime - although there has been some East African
terrorism here in the past year.

Then I meet Erin from the partner and donor
organisation to the project - World Vision. World Vision is a
huge worldwide, non-governmental organisation. They are one of the
few who work in mental health. I hadn’t realised how enormous they
are and even in Uganda they are a huge operation. They are children
focussed and Christian, but are
clear about never evangelising and are open to
beneficiaries of all backgrounds.Erin is in her twenties and leaves
me speechless with her mastery of the NGO world, policies and
ability to synthesise varied and complex concepts in a concise way
that even I can understand. They are a very impressive
organisation.

A pleasant supper in the almost dark dining
room that evening.

Day three - Kampala

I meet with the formidable and delightful Dr.
Sheila. She works in the Ministry of Health and is lead for
mental health in Uganda.

I had met Sheila once before in Italy at a
conference on mhGAP. Sheila is a Public Health Physician and
has a background in mental health work. She has a remarkable
drive and vision on mental health in Uganda. In Africa it is
so important to have key people with a commitment to mental health.
This whole project would have no beginning middle and end without
the backing of Sheila. I know that she can make the project
work.

My job was to gather background information on mental
health and health systems in Uganda. It was a struggle to keep up
with Sheila’s pace as she is so passionate on the subject and knows
it from the ground up.

In the end, I felt that I knew more about
the health service in Uganda than the health service in the
UK. There is a very well structured tiered layer of health clinics
running down from national and regional centres. The health
centres feed into a volunteer village level - the
Village Health Team. There are two national psychiatry centres
close to the capital Kampala.

Sheila, I believe, is actually the most
important part of the project as she has been with mhGAP from its
launch in WHO. She really drives the mental health agenda in
Uganda. Uganda is lucky to have such a dynamic force.

Day four - Kiboga district in the
west of Uganda

Today's task was interviewing health
workers on their services. Armed with my notebook and my WHO
copy of mhGAP manual, I headed to a rural area in the west of
Uganda. This was a three hour drive from Kampala along mud
roads past villages with no water or electricity. The poverty was
overt.

We met a health worker who was clearly
committed to her work but struggled to understand concepts of
mental illness. When I asked about schizophrenia she talked about
referring to an ear specialist for hearing problems. Yet when I
left the little corrugated roof building, I soon saw a homeless man
who was clearly psychotic and homeless.

The next practice was in a much better
building and supported by Irish Aid. Here there were two skilled
health workers. Yet here they said they didn’t see any mental
illness. Just before I started to speak to them I saw a young
Ugandan lady with four children. She looked depressed and sad.
They told me she attended frequently with physical health problems.
They had never asked her about depression. However, when I talked
to them about it and showed them the manual I could see that them
make the connection. I know they will ask her about this next
time and maybe think a bit more about mental health. I hope in the
future all these areas will have access to mental health
information. In the meantime people are referred on for further
advice through the layers of health services.

At this stage I felt this was real volunteer
work - going to clinics, seeing front line workers and getting
my hands dirty.

March 2012

I wasn’t originally going to write a blog on this assignment as
I considered it would be an uninteresting read in terms of the
nature of the mission here.

However, after some rumination
and discussion with colleagues, I thought maybe it
would be good to show the more mundane part of international
development work. I love doing direct clinical care, training
and training of the trainer, but this was work was almost
entirely paper-based. Also I was stuck indoors in a
giant eight day meeting.

I have always said that if you are doing
international work right it is probably somewhat dull. I wouldn’t
describe my experience in Uganda as dull even though it
may sound dull being stuck in workshop for eight days. It
was actually a fascinating experience and I learned a huge amount
of how to do this work right.

February 2012

As Idi Amin is no longer President of Uganda, some of
the Asians he drove out are coming back. Uganda has been at peace
for about seven years now which is why many are incensed at
Joseph Kony,Lord Liberation Army, who gave the impression that
Uganda is still at war.

Tackling AIDSs has been an astounding success
but the rate is increasing again. People are highly aware of HIV
and prevention is though a multi-pronged campaign of education.

Uganda is known for its homophobia but is
probably not much different to many other countries in the
region. I know that there are those in UK who feel that we
should not support Uganda because of this. It is a tricky area. At
least in mental health we' re committed to designing
programmes which are non-judgemental, where
there's unconditional respect for all patients and carers.

One of the big challenges facing Uganda at the
moment is the increasing rates of the bizarre,chilling and
unexplained Nodding disease in the north of the country. In this
condition, children between 5 to 15, developa nodding
motion when faced with food and stop eating. They eventually die.
In Uganda it falls under mental health. It appears that the disease
has been spread by hysteria but there are more conventional
medical cases. It is also found in South Sudan and a few other
countries and is currently the subject of an
international health investigation. Our health ministry colleagues
were very preoccupied with Nodding disease and it'll be a big
challenge to a poor country.

In February 2012, WHO contact me (out of blue)
to ask if I would be interested in doing some work in Uganda based
on the mhGAP. After about 2 seconds I said yes. I am passionate
about the mhGAP approach, especially incorporating mental health
into primary care.

In case anyone still hasn’t heard me talk
about this - this is the WHO approach of addressing the inequality
of mental health provision in low and middle income countries. It
means that mental health is brought to primary care level and
health workers are trained to identify and treat basic mental
health problems. They refer on any that are in any way complex. It
is a double system of primary care mental health clinics with
secondary referral systems for complex cases. There is a manual
that is a guide to management. Coupled with this are training
materials and supervision systems. It is a way of scaling up mental
health in places that wouldn’t have access to any service
otherwise. Conditions covered are the MNS conditions –
mental, neurological and substance abuse. So the anomaly, for a
western psychiatrist, is that epilepsy is part of the mental
health system.

This can work as long as there is a political,
training, supervision drive and a robust secondary referral
mechanism. So with all this in the background I was proud to be
asked by WHO to be part of the design planning of a programme to
scale up mhGAP in parts of Uganda.